Pragmatic global health
Authors: None The Lancet Global Health
Journal: The Lancet Global Health (2023)

Global health as a knowledge system remains marred by (neo)colonialism, which instils and maintains worrisome asymmetries of power. Moreover, global health solutions all too often fall foul of overmedicalisation: the tendency to focus exclusively on biomedical solutions to control individual risk factors without tackling deep-rooted social determinants of health through political and social actions. The co-existence of colonialism and overmedicalisation has enabled parachute (or helicopter) research and a persistent gap between knowledge and practice, as the real-world usability of the evidence produced is seldom the primary focus in this research paradigm. There is no simple, immediate solution for these threats to global health, but taking a more pragmatic approach seems a good place to start. A pragmatic approach could contribute to shrinking the knowledge–practice gap and maximising real-world implications through a multidimensional effort that centres on local needs and participation. Being pragmatic in global health primarily means adopting a consequentialist perspective—ie, oriented by the practical consequences of interventions. Outcomes with practical implications are more than just statistically significant results (ie, attaining a p value of less than an artificial threshold) from clinical trials conducted in a controlled environment. The practical implications of any evidence-based interventions depend on the usability of interventions in practice. And usability can only increase through meticulous consideration of the contexts in which the evidence is produced and applied, the actors who implement the intervention, and the current and future impact on local populations. The consequentialist perspective thus echoes the core aim of implementation research: to explore what, where, when, why, how, and for whom interventions work in real-world settings. We believe that a combination of implementation research and a pragmatic approach is what is required to close the knowledge–practice gap in global health. In addition, the pragmatic approach is pluralistic. A 2021 review defined global health as multifaceted, like a Swiss Army knife, with many tools available. Yet, the few tools with sharp quantitative edges tend to be the most often applied, regardless of whether they are the most efficient and effective. Pragmatic global health advocates for a multidisciplinary, multisectoral, cross-cultural, and transnational perspective. For example, adopting a multidisciplinary perspective can enrich knowledge production, instead of viewing global health exclusively through a biomedical lens. Qualitative investigations can present experiences and narratives from several stakeholders, to achieve a deeper understanding of the context. And systems thinking can facilitate the management of the complexity and interconnectedness in the health system. Similarly, the importance of consolidation of efforts from different sectors and cultures is a key component of the pragmatic and pluralistic global health we would like to advocate for. Most importantly, the pragmatic approach advocates a shared agency for local people that enables sufficient dialogue, consensus, and collaboration between different stakeholders in global health. It must be people-centred—from the community, by the community, and for the community. The empowerment of local actors and the engagement of all stakeholders (not just wealthy funding bodies and external experts) are in line with a decolonising agenda that requires radical structural changes of power relationships towards equity and global justice. Under all global health approaches, local communities are subject to the consequences of inaction, but empowerment of the communities gives them the capacity and the responsibility to act. Nonetheless, recalibrating to the pragmatic approach has its own challenges. For example, the pivot to implementation research needs support from funders, publishers, and researchers alike. Multidisciplinary and multisectoral collaboration requires humility and solidarity where competition with and lack of knowledge of other disciplines or sectors are common. Additionally, effecting the pragmatic approach would require high tolerance for and adaptability to complexities and uncertainties in real-world settings that many researchers are not used to. Pragmatism is not a radically new approach, but we need to move beyond words to action. Implementing the pragmatic approach will be a dynamic and challenging process, but we are prepared to play our part in making the switch. Resisting unchecked pragmatism in global healthThe Lancet Global Health March 2023 Editorial takes a bleak view of some of the most harmful expressions of power and politics that undermine the realisation of global health: coloniality, biomedicalisation, depoliticisation, extractivism, and self-interest.1 These expressions of power are so interwoven into the history and contemporary practice of global health that it has been suggested it might not be possible to achieve a decolonised global health,2 or that with effective anti-colonial action global health might altogether cease to exist. Full-Text PDF Open Access